A systematic review of proactive psychiatric consultation on hospital length of stay

Longer hospitalizations, more complications, and greater readmissions for patients with comorbid psychiatric disorders undergoing pulmonary lobectomy

OBJECTIVE

To examine the influence of comorbid psychiatric disorders (PSYD) on postoperative outcomes in patients undergoing pulmonary lobectomy.

METHODS

A retrospective analysis of the Healthcare Cost and Utilization Project Nationwide Readmissions Database from 2016 to 2018 was performed. Patients with lung cancer with and without psychiatric comorbidities who underwent pulmonary lobectomy were collated and analyzed (International Classification of Diseases, 10th Revision, Clinical Modification Mental, Behavioral and Neurodevelopmental disorders [F01-99]). The association of PSYD with complications, length of stay, and readmissions was assessed using a multivariable regression analysis. Additional subgroup analyses were performed.

RESULTS

A total of 41,691 patients met inclusion criteria. Of these, 27.84% (11,605) of the patients had at least 1 PSYD. PSYD was associated with a significantly increased risk of postoperative complications (relative risk, 1.041; 95% CI, 1.015-1.068; P = .0018), pulmonary complications (relative risk, 1.125; 95% CI, 1.08-1.171; P < .0001), longer length of stay (PSYD mean, 6.79 days and non-PSYD mean, 5.68 days; P < .0001), higher 30-day readmission rate (9.2% vs 7.9%; P < .0001), and 90-day readmission rate (15.4% vs 12.9%; P < .007). Among patients with PSYD, those with cognitive disorders and psychotic disorders (eg, schizophrenia) appear to have the highest rates and risks of postoperative morbidity and in-hospital mortality.

CONCLUSIONS

Patients with lung cancer with comorbid psychiatric disorders undergoing lobectomy experience worse postoperative outcomes with longer hospitalization, increased rates of overall and pulmonary complications, and greater readmissions suggesting potential opportunities for improved psychiatric care during the perioperative period.

Patient and Medical Unit Staff Experiences of Proactive and Integrated Consultation-Liaison Psychiatry in The HOME Study: A Qualitative Investigation

BACKGROUND

Consultation-liaison (C-L) psychiatry services aim to help general hospital staff provide better care for their patients. Recently, many inpatient C-L psychiatry services have adopted proactive and integrated approaches to achieve this aim. Despite these developments, there have been no interview-based studies of patients' and staff members' experiences of the new approaches.

OBJECTIVE

To gain an in-depth understanding of patients' and medical unit staff members' experiences of a proactive and integrated C-L psychiatry service for older medical inpatients (Proactive Integrated C-L Psychiatry [PICLP]).

METHODS

We conducted an interview-based qualitative study with thematic analysis. The participants were patients and staff who had experienced PICLP during The HOME Study, a randomized trial that evaluated PICLP in 24 medical units of three UK general hospitals.

RESULTS

We conducted 97 interviews: 43 with patients or their proxies (family members who were interviewed on behalf of patients with significant cognitive impairment) and 54 with staff members of all relevant disciplines. Patients and staff both described how PICLP was a helpful addition to medical care and discharge planning. It enhanced the medical unit team's ability to address psychological, psychiatric, and social needs and provide patient-centered care. They welcomed proactive biopsychosocial assessments and the broader perspective that these offered on patients' complex problems. They also valued the integration of C-L psychiatrists into the unit teams and their daily contact with them. For patients, it fostered a therapeutic relationship and helped them to be more engaged in decisions about their medical care and discharge planning. For staff, it enabled ready access to psychiatric expertise and training opportunities. The few reported experiences of PICLP being unhelpful were mainly about the greater number of clinicians involved in patients' care and a lack of clarity about professional roles in the integrated team.

CONCLUSIONS

We found that older inpatients and medical unit staff experienced PICLP as both acceptable and generally helpful. Our findings add to the existing evidence for the benefits of proactive and integrated C-L psychiatry services.

An Observational Study of Proactive and On-Request Psychiatry Consultation Services: Evidence for Differing Roles and Outcomes

BACKGROUND

Proactive psychiatric consultation services rapidly identify and assess medical inpatients in need of psychiatric care. In addition to more rapid contact, proactive services may reduce the length of stay and improve staff satisfaction. However, in some settings, it is impractical to integrate a proactive consultation service into every hospital unit; on-request and proactive services are likely to coexist in the future. Prior research has focused on changes in outcomes with the implementation of proactive services.

OBJECTIVE AND METHODS

This report describes differences between contemporary proactive and on-request services within the same academic medical center, comparing demographic and clinical data collected retrospectively from a 4-year period from the electronic medical record.

RESULTS

The proactive service saw patients over four times as many initial admissions (7592 vs. 1762), but transitions and handoffs between services were common, with 434 admissions involving both services, comprising nearly 20% of the on-request service's total contacts. The proactive service admissions had a shorter length of stay and a faster time to first psychiatric contact, and the patients seen were more likely to be female, of Black race, and to be publicly insured. There were over three times as many admissions to psychiatry from the proactive service. The on-request service's admissions had a longer length of stay, were much more likely to involve intensive care unit services, surgical services, and transfers among units, and the patients seen were more likely to die in the hospital or to be discharged to subacute rehabilitation.

CONCLUSIONS

Overall, the results suggest that the two services fulfill complementary roles, with the proactive service's rapid screening and contact providing care to a high volume of patients who might otherwise be unidentified and underserved. Simultaneously, the on-request service's ability to manage patients in response to consult requests over a much larger area of the hospital provided important support and continuity for patients with complex health needs. Institutions revising their consultation services will likely need to consider the best balance of these differing functions to address perceived demand for services.

Using Discrete Form Data in the Electronic Medical Record to Predict the Likelihood of Psychiatric Consultation

BACKGROUND

Manually screening for mental health needs in acute medical-surgical settings is thorough but time-intensive. Automated approaches to screening can enhance efficiency and reliability, but the predictive accuracy of automated screening remains largely unknown.

OBJECTIVE

The aims of this project are to develop an automated screening list using discrete form data in the electronic medical record that identify medical inpatients with psychiatric needs and to evaluate its ability to predict the likelihood of psychiatric consultation.

METHODS

An automated screening list was incorporated into an existing manual screening process for 1 year. Screening items were applied to the year's implementation data to determine whether they predicted consultation likelihood. Consultation likelihood was designated high, medium, or low. This prediction model was applied hospital-wide to characterize mental health needs.

RESULTS

The screening items were derived from nursing screens, orders, and medication and diagnosis groupers. We excluded safety or suicide sitters from the model because all patients with sitters received psychiatric consultation. Area under the receiver operating characteristic curve for the regression model was 84%. The two most predictive items in the model were "3 or more psychiatric diagnoses" (odds ratio 15.7) and "prior suicide attempt" (odds ratio 4.7). The low likelihood category had a negative predictive value of 97.2%; the high likelihood category had a positive predictive value of 46.7%.

CONCLUSIONS

Electronic medical record discrete data elements predict the likelihood of psychiatric consultation. Automated approaches to screening deserve further investigation.

Cost structure in specialist mental healthcare: what are the main drivers of the most expensive episodes?

BACKGROUND

Mental disorders are one of the costliest conditions to treat in Norway, and research into the costs of specialist mental healthcare are needed. The purpose of this article is to present a cost structure and to investigate the variables that have the greatest impact on high-cost episodes.

METHODS

Patient-level cost data and clinic information during 2018-2021 were analyzed (N = 180,220). Cost structure was examined using two accounting approaches. A generalized linear model was used to explain major cost drivers of the 1%, 5%, and 10% most expensive episodes, adjusting for patients' demographic characteristics [gender, age], clinical factors [length of stay (LOS), admission type, care type, diagnosis], and administrative information [number of planned consultations, first hospital visits, interval between two hospital episode].

RESULTS

One percent of episodes utilized 57% of total resources. Labor costs accounted for 87% of total costs. The more expensive an episode was, the greater the ratio of the inpatient (ward) cost was. Among the top-10%, 5%, and 1% most expensive groups, ward costs accounted for, respectively, 89%, 93%, and 99% of the total cost, whereas the overall average was 67%. Longer LOS, ambulatory services, surgical interventions, organic disorders, and schizophrenia were identified as the major cost drivers of the total cost, in general. In particular, LOS, ambulatory services, and schizophrenia were the factors that increased costs in expensive subgroups. The "first hospital visit" and "a very short hospital re-visit" were associated with a cost increase, whereas "the number of planned consultations" was associated with a cost decrease.

CONCLUSIONS

The specialist mental healthcare division has a unique cost structure. Given that resources are utilized intensively at the early stage of care, improving the initial flow of hospital care can contribute to efficient resource utilization. Our study found empirical evidence that planned outpatient consultations may be associated with a reduced health care burden in the long-term.

The impact of psychiatric comorbidities on emergency general surgical patients' outcomes

BACKGROUND

Psychiatric disorders are increasingly prevalent. Studies have demonstrated that the presence of comorbid psychiatric conditions (CPC) is associated with a number of worsening outcomes in hospitalised patients in general. The relationship between a wide range of psychiatric comorbidities and acute surgical presentations has not been studied to date.

STUDY DESIGN

The Hospital In-Patient Enquiry (HIPE) system and prospectively maintained eHandover were used to identify all surgical emergency admissions to Mayo University Hospital, Ireland. Patient demographics, comorbidities, primary diagnoses, length of stay (LoS), and procedures undergone were recorded over a 12-months period. Subgroup analyses examining LoS variation in surgical presentation types were performed.

RESULTS

1028 admissions occurred over this one year period, amongst 995 patients, the presence of psychiatric comorbidities increased the mean LoS by 1.9 days (p = 0.002). Comorbid depression, dementia, and intellectual disability conferred a significant increase in LoS by 2.4 days, 2.8 days and 6.7 days respectively. Subgroup analysis revealed greater LoS in patients with CPC diagnosed with non-specific abdominal pain (1.4 days, p = 0.019), skin and soft tissue infections (2.5 days, p = 0.040), bowel obstruction (4.3 days, p = 0.047), and medical disorders (18.6 days, p = 0.010). No significant difference was observed in mortality and readmission rates.

CONCLUSION

Psychiatric comorbidities significantly impact length of hospital stay and discharge planning in surgical inpatients. Greater awareness of this can facilitate better care delivery for this population to reduce the LoS and subsequent economic burden on the healthcare system.

An overview of the rehabilitation and psychiatric diagnoses of patients referred to a psychiatry consult liaison service at an inpatient rehabilitation hospital

BACKGROUND

Patients presenting for inpatient rehabilitation following injury or illness are commonly affected by comorbid psychiatric illness. Currently, little is known about the utilization of a psychiatry consult service in an inpatient rehabilitation hospital.

OBJECTIVE

To identify which rehabilitation patient populations most frequently received psychiatric consultation and recognize the most common psychiatric comorbidities after the implementation of a psychiatry consult liaison (PCL) service.

DESIGN

A retrospective observational study in the form of a chart review examining the utilization patterns of a psychiatric consultation liaison service in the inpatient rehabilitation setting. Chart review was performed to extract patient demographics (age and sex), rehabilitation diagnosis, cause of rehabilitation diagnosis (intentional, accident, self-inflicted, or disease), reason for referral to psychiatry, and psychiatric diagnosis on initial consultation. Statistical software was used for statistical analysis to answer the pre-specified research questions.

SETTING

A 178 bed, free-standing, academic rehabilitation hospital located in an urban Canadian center.

PATIENTS

Any patient admitted to the inpatient rehabilitation hospital who received a psychiatric consultation between September 2016 and December 2019 was eligible for inclusion.

RESULTS

A total of 1016 charts were reviewed in the initial chart review and  1008 were included. The most common rehabilitation diagnoses that were associated with a psychiatric consult were (% admissions receiving consultation): amputations (38%); burns (35%), neurologic disorder (28%), deconditioning (14%), and musculoskeletal injury (7%). Although 20% of patients did not meet criteria for a psychiatric diagnosis, most common psychiatric diagnoses included mood disorder, adjustment disorder, neurocognitive disorder, and delirium.

CONCLUSION

There are significant perceived needs for psychiatric services in the inpatient rehabilitation setting. Although some patient groups such as patients with amputations, burns, and trauma may exhibit the highest utilization, the service supports mental health needs from many patient groups.

Implementation of an embedded behavioral health care model in a pediatric rheumatology subspecialty juvenile myositis clinic

Youth with chronic medical illness, such as juvenile myositis (JM), require specialized behavioral health care. However, access to such care is challenging due to the youth mental health crisis, which impacts accessibility of mental health services in the community, as well as challenges accessing behavioral health care above and beyond the demands of care related to their JM management. In this paper we describe an embedded behavioral health care model, including the establishment and implementation of such a model, at a pediatric hospital where youth with JM receive medical care in a Center of Excellence (CoE). We describe a unique partnership with a philanthropic organization; the challenges and benefits of delivering care within this model; as well as recommendations for maximizing its effectiveness. Ultimately, we provide an example of a successful embedded behavioral health care program for youth with rare disease, which may be applied to other institutions providing similar care.

The impact of rounds with a psychiatry team in the intensive care unit: A prospective observational pilot study evaluating the effects on delirium incidence and outcomes

BACKGROUND

Delirium in the intensive care unit (ICU) is a common but serious condition that has been associated with in-hospital mortality and post-discharge psychological dysfunction. The aim of this before and after study is to determine the effect of a multidisciplinary care model entailing daily ICU rounds with a psychiatrist on the incidence of delirium and clinical outcomes.

OBJECTIVE

To assess the impact of a proactive psychiatry consultation model in the surgical ICU on the incidence and duration of delirium.

METHODS

This was a prospective, single institution, observational controlled cohort pilot study of adult patients admitted to a surgical ICU. A control group that received standard of care (SOC) with daily delirium prevention care bundles in the pre-intervention period was compared to an intervention group, which had a psychiatrist participate in daily ICU rounds (post-intervention period). The primary outcome was delirium incidence. The secondary outcomes were: delirium duration, ventilator days, hospital and ICU length of stay, and in-hospital mortality.

RESULTS

A total of 104 patients were enrolled and equally split between SOC and intervention groups; 95 contributed to analysis. The overall incidence of ICU delirium was 19%. SOC and intervention groups had similar rates of delirium (21% vs 18%, p = 0.72). None of the secondary outcomes statistically significantly differed between the two groups.

CONCLUSION

Delirium in ICU patients is a potentially preventable condition with serious sequelae. There was no difference in delirium incidence or duration between patients receiving SOC or patients who had multidisciplinary rounds with a psychiatrist.

Proactive psychological and psychiatric support of patients with chronic non-communicable diseases in a randomised trial: a Ukrainian experience

Background

Presently, approaches for the early treatment of pathological anxiety in patients with chronic non-communicable diseases are lacking, thus delaying the initiation of symptom management at the early onset of the illness. Proactive psychological and psychiatric support, to alleviate subclinical symptoms of anxiety and to improve the quality of life in patients with chronic non-communicable diseases, is a promising candidate for the role of such therapy.

Aims

To investigate and determine the effectiveness of proactive psychological and psychiatric support for alleviating subclinical symptoms of anxiety and improving quality of life, in patients with chronic non-communicable diseases.

Methods

The study design was a monocentric randomised controlled trial with parallel groups. The study, involving 193 inpatients with chronic non-communicable diseases, complied with the ethical and deontological norms in accordance with the principles set out in the Declaration of Helsinki. Instruments used in the study included the Hamilton Anxiety Scale (HAM-A) to assess subclinical symptoms, the Scale of Somatic Symptoms and the Chaban Quality of Life Scale. Block randomisation was used to randomise patients to a 2-month-long study group with a proactive counselling psychiatry model care or a control group with standard regulated treatment for chronic non-communicable diseases. The allocation ratio was 1.15:1 owing to the expectancy of a higher percentage of dropout in the intervention group.

Results

After 60 days of treatment (T2), there was a statistically significant difference in all clinical parameters between the study and control groups. The median HAM-A value differed between the groups by 4.87 points, with statistically significant lower results in the study group. The comparison of the study group's scale values on day 1 and day 60 demonstrated statistically significant changes in all three indicators.

Conclusions

Our results support existing evidence for the effectiveness of proactive psychological and psychiatric support to reduce subclinical anxiety and somatisation symptoms and to improve the quality of life for patients with common chronic non-communicable diseases. However, continued research on the effectiveness of proactive psychological and psychiatric support for patients with chronic non-communicable diseases is needed.

The impact of Mental Health Nurse Consultants on the care of general hospital patients experiencing concurrent mental health conditions: An integrative literature review

Mental Health Nurse Consultants are advanced practice mental health nurses who consult with nurses and other health professionals in a general hospital setting. The aim of this review was to analyse and synthesize the available evidence related to the impact of Mental Health Nurse Consultants on the care of general hospital patients experiencing concurrent mental health conditions. The integrative literature review method was utilized as it allows for the inclusion and integration of quantitative, qualitative, and mixed methods research which produces a synthesized understanding of data to inform practice, policy, and research. The Preferred Reporting Items of Systematic Review and Meta-Analyses guided the search strategy. All published studies examining the impact of clinical consultations provided by Mental Health Nurse Consultants on the mental health care of general hospital patients were included. The 19 selected articles were from North America, Australia, the United Kingdom, and Europe. Fifteen were quantitative, three were qualitative, and one used mixed methods. The findings highlight the role is generally positively received by hospital staff. The results indicate that clinical consultations provided by Mental Health Nurse Consultants (i) may improve patient experiences of mental health conditions, (ii) influence aspects of care delivery, (iii) are valued by staff, particularly nurses, and (iv) increase staff competence and confidence in the provision of mental health care. The review highlighted significant limitations of the available evidence, the need for contemporary discussion and debate of MHNC theory and practice, and further evaluation of the role to inform future service delivery.

Early liaison psychiatry consultations and general hospital readmission: A retrospective cohort study

BACKGROUND

Readmission rates are under growing scrutiny as an indicator of quality of care as much as a potential source of savings. Patients with comorbid psychiatric conditions are more likely to be readmitted, so Consultation-Liaison Psychiatry (CLP) may play a role in lowering readmission rates.

METHOD

In this retrospective cohort study conducted in a general hospital in Paris, France, all consecutive adult inpatients referred for the first time to CLP from January 2008 to December 2016, were included. The main outcomes were 30-day and 7-day readmissions in the same hospital, excluding iterative and planned stays. The objective of this study is to determine whether the timing of psychiatric consultations is associated with 30-day and 7-day readmission rates.

RESULTS

A total of 4498 inpatients (2298(51·1%) women, age = 59·8(±19·3) years) were referred to CLP. Adjusting for age, sex, place of residence, year of admission, type of ward, psychiatric diagnosis and disease severity, later consultation was associated with higher 30-day and 7-day readmission rates (adjusted Odds Ratio [95% confidence interval]:1.21[1·10-1·33] and 1·26[1·11-3·13], respectively). Further adjusting for length of stay, the association remained significant for 7-day readmission (1.28[1·05-1·57]). After stratification on the length of stay, for stays in the highest tercile (i.e., >21 days) an intervention after day 3 (versus before) was associated with 30-day and 7-day readmission rates of 15·8% versus 8·6%(1·81 [1·11-3·13]) and 4·9% versus 1·8%(2·98[1·16-9·88]), respectively.

CONCLUSION

Earlier psychiatric consultation was associated with fewer 30-day and 7-day readmissions. Interventional studies are needed to show that proactive CLP teams could help general hospitals to improve quality of care and make significant economic savings.

Why mental health service delivery needs to align alongside mainstream medical services

There is significant individual human suffering and economic burden because of untreated mental health and substance use disorders. There is high psychiatric morbidity in primary and secondary medical care. At least one-fifth of patients attending primary care services in western countries pertain to mental health and one-third of patients attending general hospitals have a comorbid mental disorder. Patients with mental disorders have lower life expectancy than the general population due to various medical conditions and reduced access to physical healthcare. There is a suicide every 40 seconds and the vast majority of those who die by suicide have a diagnosable mental disorder. Despite this, most countries spend less than 2% of their health budgets on mental health. Effective treatments exist for mental disorders, however underfunding, poor integration of services, lack of trained health care professionals and stigma often prevent access to effective treatments. Stigma is a significant barrier to seeking help and receiving treatment. Geographical separation of mental health services from general hospital settings may be perpetuating the stigma of mental illness among the population. In this article, we review the key reasons why mental health services globally need to align with mainstream healthcare services and the longstanding reasons that necessitate the need to make mental health a public health priority.

Towards identifying cancer patients at risk to miss out on psycho-oncological treatment via machine learning

Objective

In routine oncological treatment settings, psychological distress, including mental disorders, is overlooked in 30% to 50% of patients. High workload and a constant need to optimise time and costs require a quick and easy method to identify patients likely to miss out on psychological support.

Methods

Using machine learning, factors associated with no consultation with a clinical psychologist or psychiatrist were identified between 2011 and 2019 in 7,318 oncological patients in a large cancer treatment centre. Parameters were hierarchically ordered based on statistical relevance. Nested resampling and cross validation were performed to avoid overfitting.

Results

Patients were least likely to receive psycho‐oncological (i.e., psychiatric/psychotherapeutic) treatment when they were not formally screened for distress, had inpatient treatment for less than 28 days, had no psychiatric diagnosis, were aged 65 or older, had skin cancer or were not being discussed in a tumour board. The final validated model was optimised to maximise sensitivity at 85.9% and achieved an area under the curve (AUC) of 0.75, a balanced accuracy of 68.5% and specificity of 51.2%.

Conclusion

Beyond conventional screening tools, results might contribute to identify patients at risk to be neglected in terms of referral to psycho‐oncology within routine oncological care.

An Economic Evaluation of a Proactive Consultation-Liaison Psychiatry Pilot as Compared to Usual Psychiatric Consultation On-Demand for Hospital Medicine

BACKGROUND

A growing literature demonstrates the value of the Proactive Consultation-Liaison (C-L) Psychiatry model for healthcare systems through reductions in hospital length of stay (LOS). Few studies include financial outcomes. We evaluated the return on investment (ROI) of a one-year Proactive C-L Psychiatry pilot on a hospital medicine unit.

METHODS

We used a pre-post method with an active comparison of three hospital medicine units with regular psychiatric consultation on-demand. We staffed the Pilot unit with one full-time psychiatrist who focused on early case finding, close communication with unit staff, frequent follow-up visits, and proactive discharge planning. We assessed the one-year change in mean LOS for all patients receiving psychiatric consultation, from which we estimated the direct contribution margin (DCM) from bed backfills and the program's return on investment (ROI).

RESULTS

On the Pilot unit, the percent of discharges that received psychiatric consultation increased from 7.34% to 13.79%, and the LOS for patients consulted on declined by a mean of 1.82 days (P<0.05), as compared to an increase of 0.15 days (P>0.05) on the usual care units. The Pilot unit reduction in LOS saved 451.71 days total, allowing for 73.81 bed-backfills, a DCM of $419,343 (95% confidence interval, $50,754 to $787,933), a net DCM of $298,245 (-$70,344 to $666,835) and ROI of 132% (-31% to 295%).

CONCLUSION

This study strengthens existing evidence for the relative cost-effectiveness of Proactive Consultation-Liaison (C-L) Psychiatry for hospital medicine compared to usual psychiatric consultation on-demand.

Changes of consultation-liaison psychiatry practice in Italian general hospitals: A comparative 20-year multicenter study

INTRODUCTION

Conducted under the auspices of the Italian Society of Consultation Liaison Psychiatry (SIPC) the aim of this study was to describe the characteristics of Consultation Liaison Psychiatry (CLP) activity in Italy (SIPC-2-2018) over the past 20 years by comparing with data from the first Italian nation-wide study (SIPC-1-1998).

METHODS

We collected data on CLP visits of 3,943 patients from 10 Italian hospitals over a period of 1 year. Data were compared with those from the SIPC-1 1998 study (4,183 participants). Patients were assessed with the same ad hoc 60-item Patient Registration Form recording information from five different areas: Sociodemographic, hospitalization-related, consultation-related, interventions and outcome.

RESULTS

Compared with participants from the previous study, SIPC-2-2018 participants were significantly older (d = 0.54) and hospitalized for a longer duration (d = 0.20). The current study detected an increase in the proportion of referrals from surgical wards and for individuals affected by onco-hematologic diseases. Depressive disorders still represented the most frequent psychiatric diagnosis, followed by adjustment and stress disorders and delirium/dementia. Also, CLP psychiatrists prescribed more often antidepressants (Φ = 0.13), antipsychotics (Φ = 0.09), mood stabilizers (Φ = 0.24), and less often benzodiazepines (Φ = 0.07).

CONCLUSION

CLP workload has increased considerably in the past 20 years in Italy, with changes in patient demographic and clinical characteristics. A trend toward increase in medication-based patient management was observed. These findings suggest that the psychiatric needs of patients admitted to the general hospital are more frequently addressed by referring physicians, although Italian CLP services still deserve better organization and autonomy.

Proactive Integration of Mental Health Care in Hospital Medicine: PRIME Medicine

BACKGROUND

Proactive consultation-liaison (C-L) psychiatry has been shown to reduce hospital length of stay (LOS), increase psychiatric C-L consult rate, and improve hospital staff satisfaction. Nursing attrition has not been studied in relation to proactive C-L.

OBJECTIVE

Our primary aim in evaluating the proactive C-L service called Proactive Integration of Mental Health Care in Medicine (PRIME Medicine) is to analyze change in LOS over 10 months using historical and contemporary comparison cohorts. As secondary aims, we assess change in psychiatric consultation rate, time to consultation, and change in nurse attrition.

METHODS

PRIME Medicine was implemented in 3 hospital medicine units as a quality-improvement project. Team members systematically screened patients arriving to assigned units for psychiatric comorbidity. Identified patients were reviewed with hospitalist teams and nurses with the goal of early intervention.

RESULTS

Including historical and contemporary comparison cohorts, the mean sample age was 62.4 years (n = 8884). Absolute LOS was unchanged, but difference-in-difference analysis trended toward reduced LOS by 0.16 day (P = 0.08). Consultation rate increased from 1.6% (40 consults) to 7.4% (176 consults). Time to consultation was unchanged (4.0-3.8 d). Annual per-unit nursing turnover increased from 4.7 to 5.7 in PRIME units but from 8.5 to 12.0 in comparison units. Nurses citing "population" as the reason for leaving decreased from 2.7 to 1.7 in PRIME units but increased from 1.5 to 4.5 in comparison units. PRIME Medicine led to increased consultation rate, and our unit-wide outcomes provide a conservative estimate of effect. Factors that may have influenced effect size include our cohort's advanced age, considerable emergency department boarding times, increasing proportion of patients discharged to skilled nursing facilities, and concurrent LOS-reduction initiatives on all units. The favorable trends in nursing attrition on PRIME units may be explained in part by our prior finding that PRIME Medicine was associated with enhanced nursing satisfaction.

CONCLUSIONS

While PRIME Medicine had no more than a modest effect on LOS, it was associated with a markedly increased psychiatric consult rate and favorable trends in nursing retention. This analysis highlights important factors that should be considered when implementing and determining value metrics for a proactive C-L service.

The effectiveness of inpatient consultation-liaison psychiatry service models: A systematic review of randomized trials

OBJECTIVE

To systematically review randomized trials of the effectiveness of inpatient Consultation-Liaison (C-L) Psychiatry service models in improving patient outcomes, reducing length of hospital stay and decreasing healthcare costs.

METHOD

We searched databases including Ovid Medline, Ovid Embase, Ovid PsycINFO and EBSCO CINAHL for relevant trials. Two independent reviewers assessed articles and extracted data. The review is registered with PROSPERO, number CRD42019120827.

RESULTS

Eight trials were eligible for inclusion. All had methodological limitations and all were published more than ten years ago. None reported clear evidence that the C-L Psychiatry service model evaluated was more effective than usual medical care alone. All the service models tested focused on providing a consultation for patients identified by screening. Clinical heterogeneity precluded meta-analysis.

CONCLUSION

Whilst we found no evidence that any of the inpatient C-L Psychiatry service models evaluated is effective, the sparseness of the literature and its methodological limitations preclude strong conclusions. The trials do, however, suggest that purely consultation-based service models may not be effective. A new generation of robust clinical trials of a wider range of C-L Psychiatry service models is now required to inform future service developments.

Mortality Rates during Hospitalization and Affecting Factors in Geriatric Delirium Patients: a Retrospective Cohort Study

Background and Purpose

The purpose of this study was to investigate the prevalence of mortality during hospitalization among patients diagnosed with delirium at geriatric consultations requested in the previous one year, together with the factors affecting this.

Methods

The electronic medical records of geriatric consultations requested from the psychiatry department between January 1, 2019 and December 31, 2019 were examined from the automation system. The 200 geriatric delirium patients were included in the study. Patients' age, sex, length of hospital stay (LOHS), time between hospitalization and consultation, the department requesting consultation, reason for consultation request, psychiatric recommendations after consultation, reason for hospitalization, number of comorbid medical diseases, number of daily medications used, and history of psychiatric disease were retrieved from the electronic medical records in the automation system.

Results

LOHS and time from hospitalization to consultation were longer in the exitus group. Numbers of comorbid disease and daily medications used were higher in the died patients. Male gender, higher numbers of comorbid diseases, and daily medications were predictors of death.

Conclusions

Early detection of delirium may be important for short term results of disease. When evaluating these patients, reviewing the drugs used as much as possible can affect the outcome of the disease.

Mental disorders, length of hospitalization, and psychopharmacy-New approaches to identify barriers to psychological support for patients with cancer

BACKGROUND

Despite abundant evidence that emotional distress is frequent in cancer patients and associated with adverse health outcomes, distress screening rates and adequate referrals to psychological support programs among those in need are insufficient in many cancer centers. We therefore aimed to analyze patient- and treatment-related barriers to distress screening and referrals to psychological support as a mandatory component of best-practice cancer care.

METHOD

In the present explorative study, latent class analysis was used to identify homogeneous subgroups among 4837 patients diagnosed with cancer between 2011 and 2019.

RESULTS

Four subgroups were identified. Patients with a mental disorder and psychopharmacology were least probable to be screened for distress. Together with patients aged 65 or older and male patients, they were also less likely to receive psychological support. Patients hospitalized for 28 days or longer were most likely to be both screened and to receive psychological support.

CONCLUSIONS

Clinicians and researchers are recommended not neglect patients with mental disorders and psychopharmacological treatment as well as male and elderly patients when screening for distress and providing access to psychological support.

[Early Detection of Psychological Comorbidity in Patients Admitted to Dermatological and Internal Medicine Wards: A New Care Model for Psychosomatic Consultation Service]

This article explains the development and implementation of a psychosomatic screening and consultation service for inpatient somatic care. Approximately one in six somatic inpatients has a mental disorder. It is estimated that only half of these cases are properly identified. Consequently, a large proportion of patients remains untreated. To address this gap in care, a psychosomatic early detection programme was developed by an interdisciplinary working group. This programme is based on the Patient Health Questionnaire-4 (PHQ-4), a psychometrically very well evaluated ultra-short screening questionnaire for the detection of depressive and anxiety disorders. For implementation in routine inpatient care, the PHQ-4 was programmed as a form in the electronic medical record and administered by nursing staff during the admission interview. If the PHQ-4 screening result indicates the presence of a mental comorbidity and the patient expresses a wish for assessment of this disorder, a psychosomatic consultation is automatically ordered. The PHQ-4 was implemented into the clinical routine in four internal medicine and three dermatology wards of the University Medical Center Hamburg-Eppendorf. Documentation of the early diagnosis in the electronic patient record is a minimally costly, less time-consuming and practicable method of providing patients with holistic care through rapid interdisciplinary referral. An evaluation of cost-effectiveness, clinical efficiency, and acceptance is still pending.

Telemedicine Psychiatric Consultation on an Inpatient Obstetrical Labor and Delivery Unit

BACKGROUND

Limited access to mental health resources has challenged clinicians in delivering early behavioral health interventions to perinatal populations. We describe telepsychiatry consultations to a rural hospital's labor and delivery unit.

OBJECTIVE

To demonstrate how consultation-liaison services during peripartum hospitalization could meet this need.

METHODS

One-year data from electronic medical records of women who were at risk of postpartum syndromes and offered a telepsychiatry consult was extracted and reviewed.

RESULTS

A total of 85 consults were conducted via telepsychiatry primarily for depression, anxiety, and medication management. Bedside psychotherapeutic interventions and education were provided to 63 patients, medications were initiated for 32 patients, and outpatient referrals were made for 47 patients.

CONCLUSIONS

Our results indicate that consultation-liaison telehealth can successfully engage at-risk mothers in psychiatric treatment. Given accelerated telemedicine efforts due to the COVID-19 pandemic, improving access to telepsychiatry for rural, peripartum populations is an important area of development.

Potentially preventable hospitalisations for physical health conditions in community mental health service users: a population-wide linkage study

AIMS

Mental health (MH) service users have increased prevalence of chronic physical conditions such as cardio-respiratory diseases and diabetes. Potentially Preventable Hospitalisations (PPH) for physical health conditions are an indicator of health service access, integration and effectiveness, and are elevated in long term studies of people with MH conditions. We aimed to examine whether PPH rates were elevated in MH service users over a 12-month follow-up period more suitable for routine health indicator reporting. We also examined whether MH service users had increased PPH rates at a younger age, potentially reflecting the younger onset of chronic physical conditions.

METHODS

A population-wide data linkage in New South Wales (NSW), Australia, population 7.8 million. PPH rates in 178 009 people using community MH services in 2016-2017 were compared to population rates. Primary outcomes were crude and age- and disadvantage-standardised annual PPH episode rate (episodes per 100 000 population), PPH day rate (hospital days per 100 000) and adjusted incidence rate ratios (AIRR).

RESULTS

MH service users had higher rates of PPH admission (AIRR 3.6, 95% CI 3.5-3.6) and a larger number of hospital days (AIRR 5.2, 95% CI 5.2-5.3) than other NSW residents due to increased likelihood of admission, more admissions per person and longer length of stay. Increases were greatest for vaccine-preventable conditions (AIRR 4.7, 95% CI 4.5-5.0), and chronic conditions (AIRR 3.7, 95% CI 3.6-3.7). The highest number of admissions and relative risks were for respiratory and metabolic conditions, including chronic obstructive airways disease (AIRR 5.8, 95% CI 5.5-6.0) and diabetic complications (AIRR 5.4, 95% CI 5.1-5.8). One-quarter of excess potentially preventable bed days in MH service users were due to vaccine-related conditions, including vaccine-preventable respiratory illness. Age-related increases in risk occurred earlier in MH service users, particularly for chronic and vaccine-preventable conditions. PPH rates in MH service users aged 20-29 were similar to population rates of people aged 60 and over. These substantial differences were not explained by socio-economic disadvantage.

CONCLUSIONS

PPHs for physical health conditions are substantially increased in people with MH conditions. Short term (12-month) PPH rates may be a useful lead indicator of increased physical morbidity and less accessible, integrated or effective health care. High hospitalisation rates for vaccine-preventable respiratory infections and hepatitis underline the importance of vaccination in MH service users and suggests potential benefits of prioritising this group for COVID-19 vaccination.

Proactive Consultation-Liaison Psychiatry: American Psychiatric Association Resource Document

In 2019, the American Psychiatric Association Council on Consultation-Liaison (C-L) Psychiatry convened a work group to develop a resource document on proactive C-L psychiatry. A draft of this document was reviewed by the Council in July 2020, and a revised version was approved by this Council in September 2020. The accepted version was subsequently reviewed by the American Psychiatric Association Council on Health Care Systems and Financing in November 2020. The final version was approved by the Joint Reference Committee on November 24, 2020, and received approval for publication by the Board of Trustees on December 12, 2020. This resource document describes the historical context and modern trends that have given rise to the model of proactive C-L psychiatry. Styled as an inpatient corollary to outpatient collaborative care models, proactive C-L provides a framework of mental health care delivery in the general hospital designed to enhance mental health services to a broad range of patients. Its 4 elements include systematic screening for active mental health concerns, proactive interventions tailored to individual patients, team-based care delivery, and care integration with primary teams and services. Studies have found that proactive C-L psychiatry is associated with reduced hospital length of stay, enhanced psychiatric service utilization, reduced time to psychiatric consultation, and improved provider and nurse satisfaction. These favorable results encourage further studies that replicate and build upon these findings. Additional outcomes such as patient experience, health outcomes, and readmission rates deserve investigation. Further studies are also needed to examine a broader array of team compositions and the potential value of proactive C-L psychiatry to different hospital settings such as community hospitals, surgery, and critical care.

The Management Experiences, Priorities, and Challenges of Medical Directors in the Subspecialty of Consultation-Liaison Psychiatry: Results of a Needs Assessment

BACKGROUND

Medical directors need management skills, yet few studies describe the specific tasks that directors consider most important, their confidence for these tasks, and how their confidence develops. We studied these questions among directors in the subspecialty of Consultation-Liaison Psychiatry.

METHODS

A needs survey was sent to 48 registrants of a new forum for Consultation-Liaison Psychiatry directors. The survey asked about 6 professional experiences, the relative importance of 14 management tasks, and the directors' confidence in managing these tasks, using 7-point Likert scales. Correlations between experiences, task importance, and task confidence were performed.

RESULTS

Twenty-seven directors responded (56% response). The experiences that correlated most with management confidence were years in practice and health care leadership training, yet approximately half of responders were directors for ≤5 years and had received minimal training. Management tasks with the highest importance included demonstrating value of their service and roles for nonphysician clinical staff on their teams. Significant associations were identified between years in practice and confidence for leading faculty scholarship, trainee staffing ratios and roles, fee coding, measurement of faculty clinical productivity, and faculty recruitment. Leadership training correlated with confidence in demonstrating service value, measuring faculty clinical productivity, novel models of care, and growing a new service.

CONCLUSION

Consultation-Liaison directors with fewer years of experience and minimal health care management training need time and support to grow into their roles. They should be pointed toward training opportunities to improve their confidence to lead the wide range of management tasks that are important to their roles.

Is Consultation-Liaison Psychiatry 'Getting Old'? How Psychiatry Referrals in the General Hospital Have Changed over 20 Years

There is an ever-growing awareness of the health-related special needs of older patients, and Consultation-Liaison Psychiatry Services (CLPS) are significantly involved in providing such age-friendly hospital care. CLPS perform psychiatric assessment for hospitalized patients with suspected medical-psychiatric comorbidity and support ward teams in a bio-psycho-social oriented care management. Changes in features of the population referred to a CLPS over a 20-year course were analysed and discussed, especially comparing older and younger referred subjects. Epidemiological and clinical data from all first psychiatric consultations carried out at the Modena (North of Italy) University Hospital CLPS in the period 2000–2019 (N = 19,278) were included; two groups of consultations were created according to the age of patients: OV65 (consultations for patients older than 64 years) and NONOV65 (all the rest of consultations). Consultations for OV65 were about 38.9% of the total assessments performed, with an average of approximately 375 per year, vs. the 589 performed for NOV65. The number of referrals for older patients significantly increased over the 20 years. The mean age and the male/female ratio of the sample changed significantly across the years in the whole sample as well as both among OV65 and NOV65. Urgent referrals were more frequent among NOV65 and the rate between urgent/non urgent referrals changed differently in the two subgroups. The analysis outlined recurring patterns that should guide future clinical, training and research activities.

Proactive Integrated Consultation-Liaison Psychiatry: A new service model for the psychiatric care of general hospital inpatients

OBJECTIVE

To describe a new service model for the psychiatric care of general hospital inpatients, called Proactive Integrated Consultation-Liaison Psychiatry ('Proactive Integrated Psychological Medicine' in the UK).

METHOD

The new service model was developed especially for general hospital inpatient populations with multimorbidity, such as older medical inpatients. Its design was informed by the published literature and the clinical experience of C-L psychiatrists. It was operationalized by a process of iterative piloting.

RESULTS

The rationale for the new model and the principles underpinning it are outlined. Details of how to implement it, including a service manual and associated workbook, are provided. The training of clinicians to deliver it is described. The effectiveness and cost-effectiveness of this new service model is being evaluated. Whilst we have found it feasible to deliver and well-accepted by ward teams, potential challenges to its wider implementation are discussed.

CONCLUSION

Proactive Integrated Consultation-Liaison Psychiatry (PICLP) is a fusion of proactive consultation and integrated care, operationalized in a field-tested service manual. Initial experience indicates that it is feasible to deliver. Its effectiveness and cost effectiveness for older patients on acute medical wards is currently being evaluated in a large multicentre randomized controlled trial (The HOME Study).

EPA guidance on the quality of mental health services: A systematic meta-review and update of recommendations focusing on care coordination

BACKGROUND

The quality of mental health services is crucial for the effectiveness and efficiency of mental healthcare systems, symptom reduction, and quality of life improvements in persons with mental illness. In recent years, particularly care coordination (i.e., the integration of care across different providers and treatment settings) has received increased attention and has been put into practice. Thus, we focused on care coordination in this update of a previous European Psychiatric Association (EPA) guidance on the quality of mental health services.

METHODS

We conducted a systematic meta-review of systematic reviews, meta-analyses, and evidence-based clinical guidelines focusing on care coordination for persons with mental illness in three literature databases.

RESULTS

We identified 23 relevant documents covering the following topics: case management, integrated care, home treatment, crisis intervention services, transition from inpatient to outpatient care and vice versa, integrating general and mental healthcare, technology in care coordination and self-management, quality indicators, and economic evaluation. Based on the available evidence, we developed 15 recommendations for care coordination in European mental healthcare.

CONCLUSIONS

Although evidence is limited, some concepts of care coordination seem to improve the effectiveness and efficiency of mental health services and outcomes on patient level. Further evidence is needed to better understand the advantages and disadvantages of different care coordination models.

Integration of a proactive, multidisciplinary mental health team on hospital medicine improves provider and nursing satisfaction

OBJECTIVE

Psychiatric comorbidity among hospital medicine patients is common and often complicates care delivery and compromises outcomes. Team-based, proactive consultation-liaison (CL) psychiatry has been shown to reduce hospital length of stay (LOS) and care costs, but staff satisfaction with this model has not been explored in detail. Here we evaluate its impact on hospital medicine provider and nurse satisfaction.

METHODS

We implemented a team-based proactive CL service that reviews all admitted hospital medicine patients across 3 units for psychiatric comorbidity and provides unit-wide integrated mental health care. Hospital medicine staff completed surveys before and after a 6-month pilot phase: 10-item provider surveys covered resource adequacy, safety, time for healthcare improvements, and burnout; 26-item nurse surveys included the same 10 items plus 8 on behavioral health assessment competency and 8 on intervention competency. Additionally, we characterized psychiatric comorbidity, calculated consultation latency and volume and also average LOS during these 6 months.

RESULTS

The provider response rate was 57% (20/35 before; 21/37 after) and roughly a third for nurses (32/~90 and 31/~90, respectively). Providers rated 9 of 10 items as improved, including one on burnout. Nursing satisfaction improved similarly but with lower effect sizes. During the pilot (n = 1590), 71% had chart-identified psychiatric comorbidity. Consultation latency decreased by 0.86 days; consultation rate increased nearly 3-fold; and average LOS decreased by 0.33 days.

CONCLUSIONS

Team-based proactive CL psychiatry enhances provider and nurse satisfaction and may even reduce provider burnout. We also confirmed that this model is associated with reduced average LOS.